Children's Hospital Colorado Issues Comment on Medicaid Fiscal Accountability Regulation

WASHINGTON, Feb. 10 -- Zach Zaslow, director of government relations at the

Children's Hospital Colorado, has issued a public comment on behalf of the Children's Hospital Colorado of the the Centers for Medicare and Medicaid Services' proposed rule entitled "Medicaid Fiscal Accountability Regulation, Federal Register". The comment was written on Jan. 31, 2020, and posted on Feb. 6, 2020:

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On behalf of Children's Hospital Colorado, we appreciate the opportunity to provide comments on the Centers for Medicare and Medicaid Services' (CMS) Medicaid Fiscal Accountability Regulation (MFAR). We are concerned about the broad policy changes included in the proposed rule and the lack of analysis of the potential impacts of these changes on children covered by these programs and the providers who care for them. Respectfully, we request CMS withdraw the rule and conduct additional analysis about what the impact would be on the nearly 510,000 children in Colorado who are enrolled in Medicaid.

Children's Hospital Colorado is one of the nation's leading, not-for-profit pediatric healthcare networks, serving more children than any other healthcare system in our seven-state region. We are also the only freestanding level one pediatric trauma facility in our region, and care for a significant proportion of children with serious injuries, illnesses, and conditions from Colorado, New Mexico, Kansas, Montana, North Dakota, South Dakota, and Wyoming.

We believe that this rule could have broad implications on federal funding for Medicaid available to states and could lead to reductions in services and supports provided by Medicaid. At Children's Hospital Colorado, approximately 45 percent of our patients our enrolled in Medicaid and we serve more children covered by Medicaid than any other provider in our state. Supplemental payments have been critical in addressing historically low Medicaid reimbursement, where provider reimbursement is, on average, about 56 cents per $1.00 of cost (not charge). With supplemental payments, this average rises to about 68 cents per $1.00 of cost.

According to a Manatt study commissioned by the American Hospital Association, the nation's Medicaid program would face total funding reductions between $37 billion and $49 billion annually, or 5.8% to 7.6% of total program spending, if this rule is adopted. We are concerned that these significant cuts could lead to major reductions in coverage and enrollment for children in Medicaid and could lead to drastic cuts in Medicaid provider reimbursement.

The rule proposes to establish a new limit for supplemental payments to physicians and other practitioners in the Medicaid fee-for-service program. This new proposed payment limit of 50 percent of Medicaid base rates for physicians and non-physician practitioners would significantly reduce existing Medicaid reimbursement for the providers who practice at Children's Hospital Colorado. By lowering net reimbursement to even less fully cover the cost of the care currently being provided, the rule could greatly restrict needed access to specialty and subspecialty services required by our most vulnerable patient populations. As an academic medical center training the next generation of pediatric providers, we also have concerns about whether Children's Hospital Graduate Medical Education payments would be considered "base" or "supplemental" payments under this rule.

As faculty medical providers with the University of Colorado School of Medicine, our providers are currently able to leverage supplemental payment funding to implement innovative projects that align with overarching State and Federal goals for the Medicaid program, thereby ensuring a sound return on investment of supplemental Medicaid payments. In the pediatric domain, supplemental payments have facilitated greater emphasis on providing care at the right place and the right time so that patients do not have to travel long distances to reach specialty care.

As one example among many, supplemental payments have enabled continuity of the Health Care Program for Children with Special Needs (HCP), which provides specialty care across the state through telemedicine and in-person outreach to children and youth with special healthcare needs such as severe developmental disabilities. These patients not only require highly specialized care, but they also struggle disproportionately with the burden of travel to distant specialty healthcare centers. Since supplemental funding became available in State fiscal year (SFY) 2017-2018, the University of Colorado School of Medicine has operated six of these rural and frontier locations and continues to provide uninterrupted service to patients and families that rely on obtaining these services closer to home. Additional planning is under way to expand the services offered at these locations, further extending specialty care to rural locations.

Additionally, the Colorado Pediatric Psychiatry Consultation and Access Line Program (CoPPCAP), is another critical initiative funded by supplemental Medicaid payments to address Colorado's shortage of practicing child and adolescent psychiatrists by expanding the availability of child psychiatric educational, consultative, and practice support services to pediatric primary care providers across the state. This program aims to enhance coordination with existing behavioral health services to assure the efficient use of limited resources and coordination of efforts so that patients can be served in a timely manner in their pediatric medical home.

Supplemental payments allow Children's Hospital Colorado to provide multi-disciplinary asthma interventions to keep children out of the emergency department, to finance intensive behavioral health services to children with cystic fibrosis, to fund a Colorado Statewide Youth Suicide Prevention Initiative, and to provide pediatric specialty services in rural and frontier counties. These services cannot be adequately reimbursed through standard fee-for-service Medicaid and they rely on current, CMS-approved financing to be sustainable. Children's Hospital Colorado is very concerned that the proposed change puts all these services for children covered by Medicaid at risk.

We appreciate the desire for more transparency in supplemental payments and the need for reporting on the use of funds and value to Medicaid members and communities for which the payments are intended to support. In Colorado, these reporting systems are already in place to ensure transparency in how supplemental funding dollars are spent, inclusive of comprehensive direct quarterly and annual reporting to the Colorado Department of Health Care Policy and Financing on activities, projects, and benefits resulting from Medicaid supplemental payments.

Lowering the cap on practitioner payments from the average commercial rate will significantly reduce patient access in Colorado. This would significantly disrupt long-standing CMS interpretations of the law and would fail to account for the negative impact on patients receiving care at high-volume Medicaid providers, such as those providers affiliated with Children's Hospital Colorado. Alternative approaches to lowering the cap could maintain CMS' fiscal accountability goals without harming Medicaid access to the same degree. CMS should not make this part of the rule final.

Finally, we are very concerned about the regulatory timeline for implementation if the rule is adopted. We are concerned that with an immediate effective date on several of the proposed substantive changes could lead to turmoil within state budgets. If the rule is finalized when states have already set their annual budgets, any budget shortfalls could make it difficult, if not impossible, to adapt programs to these new constraints. We urge the consideration of a longer transition that would take account of the realities of state budgeting.

Thank you for your consideration of our substantial concerns with this rule. We hope that you will consider further analysis on the impacts of the proposed MFAR on children and the consequences to pediatric access to care in Colorado and beyond.

If you have any questions or need further information, please do not hesitate to contact Zach Zaslow at [email protected] or 720-777-6555.

Sincerely,

Zach Zaslow

Director, Government Relations

Children's Hospital Colorado

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